GP Management Plan (Item 721), Team Care Arrangement  (Item 723) & Review (Item 732) - GORD

Patients Details: <<Patient Demographics:Full Name>>
Date of Birth: <<Patient Demographics:DOB>>

Medicare No: <<Patient Demographics:Medicare Number>>
Does Patient identify as Aboriginal or Torres Strait Islander: <<Patient Demographics:Ethnicity>>

Address: <<Patient Demographics:Full Address>>

Pt Home Ph: <<Patient Demographics:Phone (Home)>>
Pt Mobile: <<Patient Demographics:Phone (Mobile)>>

Date GPMP/TCA completed: <<Miscellaneous:Date (short)>>

Date of previous GPMP (if applicable):
<<Date of previous GPMP (if applicable)>>

Details of Patient's Usual GP: <<Doctor:Name>> <<Doctor:Qualifications>>
Dr's Address: <<Doctor:Full Address>>

Dr's Ph: <<Doctor:Phone>>
Dr's Fax: <<Doctor:Fax>>

Assessment of patient | Patient Identified Problems / Health Care Needs | GP/Nurse identified Problems / Health Care Needs

Diagnosis: <<Diagnosis:>>
Date of Diagnosis <<Date of Diabetes Diagnosis>>

Medical / Surgical History:
<<Clinical Details:History List>>

Medications:
<<Clinical Details:Medication List>>

Allergies:
<<Clinical Details:Allergies/Adverse Reactions>>

Smoking History:
<<Clinical Details:Smoking>> Quitting Stage <<Clinical Details:Smoking Quitting Stage>>

Social History:
<<Clinical Details:Social History>>

Planned Review Date: (Recommendation: not less then 6 months after initial Management Plan)  <<Planned Review Date?>>

GPMP added to the patients records:  <<GPMP added to the patients records: >>
Copy of GPMP offered to patient: <<Copy of GPMP offered to patient:>>

I understand this Management Plan recommendations & agree to the outlined goals.
Patient Signature:	Date: <<Miscellaneous:Date (short)>>

I have explained the steps and costs involved, and the patient has agreed to proceed with the service.
GP Signature: 	Date: <<Miscellaneous:Date (short)>>

Current health need/problem

Goal
(delete inappropriate and add goals as required)

Agreed action by health professionals and patient

Review 1 
-6 months
(Add date here)

Review 2 
12 months
(Add date here)

Review 3 
18 months
(Add date here)

1. General | | | | |

Patient's understanding of GORD

Patient to have a clear understanding of GORD and patient's role in managing the condition
Typical symptoms
•	Heartburn is a burning pain that is generally felt in the chest area behind the breastbone. The burning feeling/pain moves upwards from the stomach/chest towards the neck during an episode of reflux. It can sometimes be felt in the throat.
•Regurgitation  
Atypical symptoms include
•	Chest pain 
•	Dyspepsia
•	Nausea
•	Belching, bloating
•	Hoarseness or change in voice 
•	Sore throat 
•	Cough 
Alarm symptoms include
•	Painful or difficult swallowing
•	Vomiting blood
Weight loss

Patient education  
The aim of treatment is to provide symptomatic relief (and ulcer healing where appropriate) with the first effective treatment used at the lowest effective dose and improving quality of life.

Control symptoms and prevent complications.

2. Lifestyle | | | | |

Nutrition

Maintain healthy diet

Consider referral to Dietician.
Patient education.
Avoid foods that increase/cause heartburn.
Modify size and timing of meals.
Discuss and provide written guidelines e.g. Lifescripts (www.health.gov.au/lifescripts)

Weight

Your target:
BMI:	
Waist	cm
Ideal: BMI  - 25
Men waist 94 cm
Women waist  80 cm

Consider referral to Dietician.
Monitor and assess BMI and waist circumference. 
Set immediate and achievable goals.
Encourage healthy eating and regular physical activity.
Review 6 monthly.

Physical activity

Your target: 

Ideal: Progress to at least 30 minutes moderate intensity physical activity 5 or more days per week (min 150 minutes per week)

Consider referral to Exercise Physiologist.
Patient exercise routine.
Positioning during meals and sleeping elevated on pillows may alleviate symptoms.
Discuss and provide written guidelines e.g. Lifescripts. 
Monitor progress in consultation with patient.

Smoking

Complete cessation
Avoidance of second-hand smoke.

Smoking cessation strategy:
Consider: 
- Quitline (13QUIT)
- Medication
- Behavioural and psychological support.

Alcohol intake
NHMRC Alcohol Guidelines
https://www.nhmrc.gov.au/health-advice/alcohol

Low risk alcohol consumption.
Your target:
___standard drinks per day

To reduce the risk of harm from alcohol-related disease or injury for healthy men and women, drink no more than 10 standard drinks per week and no more than 4 standard drinks on any one day.
The less you choose to drink, the lower your risk of alcohol-related harm. For some people not drinking at all is the safest option (NHMRC).

Reduce alcohol intake
Patient education
Lifescripts action plan
Assess patient medications for potential interactions with alcohol.

3. Biomedical | | | | |

Cholesterol/Lipids

Your target:
Cholesterol	mmols/L
Triglycerides	mmol/L
LDL-C 	mmol/L
HDL-C	mmol/L
Ideal:
Cholesterol  	4.0 mmols/L
Triglycerides  	<1.5 mmol/L
LDL-C  	<2.0 mmol/L
HDL-C  	> 1.0 mmol/L

Annual check.
Patient education – dietary.
Refer to dietician.
Cholesterol lowering medications where appropriate.
(Target based on CVD risk, calculation plus family history)

Blood pressure

Your target: < __
Ideal: 
< 130/80 mm Hg

Check every 6 months
Refer to dietician
Patient education

HbA1c

Your target: < __
Ideal: 
≤ 7%

Check every 3 months (6 months depending on previous levels and clinical risk)

Blood glucose level

Your target: < __
Ideal: 
< 7 mmols/L (4-6 fasting)

Based on new NDSS criteria for obtaining test strips e.g., unstable diabetes, change medication

4. Investigations | | | | |
Upper GI Endoscopy | Consider if diagnosis is unclear, symptoms persist or are not responsive to treatment, complications are suspected, or alarm symptoms (red flags) are present. | Refer for Upper GI Endoscopy | | |

5. Treatment | | | | |

Medication review

Correct use of medications, minimise side effects.

Antacids/alginates: Antacids neutralise the acidity of stomach juices and relieve heartburn quickly, although their effect is fairly short-lived. They are taken as a liquid (e.g. Gastrogel) or as a chewable tablet (e.g. Mylanta Rolltabs).   

H_2 antagonists: ranitidine (e.g. Zantac) 150 mg OR famotidine 20 mg (e.g. Pepzan) OR nizatidine (e.g. Tazac) 150 mg; orally, once or twice daily. 

Proton pump inhibitors (PPIs): omeprazole (e.g. Losec) 20 mg OR esomeprazole 20mg (e.g. Nexium) OR lansoprazole 30 mg (e.g. Zoton) OR pantoprazole 40 mg (e.g. Somac) OR rabeprazole 20mg (e.g. Pariet); orally, once daily (doubling the dose may be tried if satisfactory control is not achieved).
Warfarin Patients:- INR should be checked following introduction of PPI's

Avoid taking medications that may cause heartburn, such as aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs); or remain upright for half an hour after taking medications such as doxycycline and bisphosphonates

Patient education.
Review medications.
Consider DMMR (Item 900).

Antacids/alginates:
Rapid relief but ineffective in long-term management of anything other than intermittent symptoms.

H_2 antagonists: 
Less potent. Rapid onset, some accessible over-the-counter.

Proton pump inhibitors (PPIs):
Most potent but slower onset. Most effective if taken 15-30 minutes before food. Some (lower strength, e.g. Somac 20mg and Pariet 10mg) accessible over-the-counter.

Current advice is to move to the minimum dose that controls symptoms

6. Complications/Comorbidity of GORD | | | | |

Barret’s Oesophagus,  Hiatus Hernia, 
Ulceration,
Ca of the Oesophagus,
Helicobacter pylori status

Consider referral to a gastroenterologist to exclude.
If dysmotility is suspected, then a video barium swallow with marshmallows may delineate the underlying muscular abnormality.

Surveillance program as determined by Reflux Disease Guidelines

Exclude cardiac symptoms | Perform ECG +/- stress echo to assess cardiac disease/chest pain | | | |

Team Care Arrangements
Provider Name | Treatment/ Service/ Goals | Address | Phone Number | Has agreed to TCA | Number of visits

Investigations:
<<Summary:Investigation Results (Selected)>>

GP Management Plan & TCA for <<Patient Demographics:Full Name>>  DOB <<Patient Demographics:DOB>> Reviewed February 2020